Pedicled omental flaps in the treatment of complex spinal wounds after en bloc resection of spine tumors

Omentomyelopexy for the Treatment of a Persistent Lumbar Pseudomeningocele: A Case Report With Technical Note

BACKGROUND AND IMPORTANCE

Pseudomeningoceles are extradural accumulations of cerebrospinal fluid. In most cases, they appear as a complication of spinal operations. Omentomyelopexy is a surgery in which an autologous omentum flap is implanted over the dural opening. We describe a case of persistent pseudomeningocele treated with omentomyelopexy.

CLINICAL PRESENTATION

A 37-year-old man sustained a T12-L1 AO B3 fracture during a motorcycle accident. He underwent posterolateral fusion and then neurological rehabilitation. Two years later, however, his condition worsened, and he experienced progressive weakness-he was diagnosed with an intramedullary cyst, which was treated with laminectomy, arachnolysis and cystotomy. A pseudomeningocele developed afterward, and the patient underwent multiple reoperations in the following years, none of which were effective. Omentomyelopexy, a complex procedure aimed to facilitate cerebrospinal fluid absorption and subsequent formation of a permanent membrane, was offered to the patient as a "last resort." After undergoing omentomyelopexy, his pseudomeningocele resolved.

CONCLUSION

Although it should be reserved for exceptionally pertinent cases, omentomyelopexy is a viable option for managing persistent pseudomeningocele. However, further research is needed to better understand the effects and benefits of omentomyelopexy in this context.

Modified fourth lumbar artery local perforator flap: an alternative for reconstruction of nonhealing lumbosacral spinal defects

BACKGROUND

The reconstruction of nonhealing lumbosacral spinal defects remains a challenge, with limited options. The aim of this article was to review the authors' technique and experience with the modified fourth lumbar artery local perforator (MFLALP) flap for the coverage of nonhealing lumbosacral defects after spinal surgery.

METHODS

Between August 2012 and May 2021, we reviewed all MFLALP flaps performed for lumbosacral spinal defects. Patient demographics, wound aetiologies, surgical characteristics, and outcomes were reviewed retrospectively.

RESULTS

A total of 31 MFLALP flaps were performed on 24 patients during the research period. The median flap size was 152 cm² (range, 84-441 cm²). All flaps survived successfully, although there were two cases of minor complications. One patient had a haematoma and required additional debridement and skin grafting at 1 week postoperatively. The other patient suffered wound dehiscence at the donor site at 2 weeks postoperatively and required reclosure. The follow-up time ranged from 6 months to 5 years.

CONCLUSIONS

The MFLALP flap has the advantages of a reliable blood supply, sufficient tissue bulk and low complication rate. This technique is an alternative option for the reconstruction of nonhealing lumbosacral spinal defects.

Characteristics, survivals and risk factors of surgical site infections after En Bloc sacrectomy for primary malignant sacral tumors at a single center

INTRODUCTION

For prolonged survival, primary malignant sacral tumors (PMST) are treated by En Bloc sacrectomy. Few studies analyzed specifically the surgical site infections (SSI) for this condition and whether they impact on the patients' survivals.

OBJECTIVES

The objectives were to (1) describe their characteristics; (2) compare the survivals of infected and non-infected patients; (3) identify patients- and surgery-related risk factors.

METHODS

We conducted a retrospective single center study on 51 consecutive patients with PMST who underwent an En Bloc sacrectomy. Mean follow-up was 89±68months (range, 13-256months). Histology consisted of 46 chordoma, 3 chondrosarcoma, 1 Ewing tumor, 1 malignant peripheral nerve sheet tumor. Mean age was 57.4±13.7years with 26 (51%) male. Approaches were mainly anterior-and-posterior with, for the anterior approach, 18 laparotomy and 32 laparoscopy. Other surgical characteristics included 39 (76%) sacrectomy above S3; 7 (14%) instrumented cases; 8 (16%) colostomy. A pedicled omental flap with artificial mesh was used for posterior wall reconstruction. Overall and disease-free survivals were compared between infected and non-infected patients using Kaplan-Meier curves and log-rank test.

RESULTS

A total of 29 (57%) patients developed a SSI (7 deep, 22 organ/space) at mean 13.2±7.7days. One patient had also an infected intraperitoneal hematoma at day 150. SSIs were polymicrobial in 26 (90%) cases with Enterococcus sp. (27%) and E. coli (24%) as predominant organisms. Overall and disease-free survivals were not statistically different between infected and non-infected patients. Factors associated with increased likelihood of SSI included age>65years (OR=3.64; 1.06-12.50; p=0.04) and an elevated ASA score (OR=3.28, 1.05-10.80; p=0.046). Neoadjuvant radiotherapy (OR=2.86; 0.97-9.37; p=0.08) demonstrated a trend towards increased risk of SSI. Tumor volume, sacrectomy level, operating time, laparoscopy, colostomy, instrumentation, bowel incontinence were not associated to an increased risk of SSI.

CONCLUSION

En Bloc sacrectomy for PMST led to frequent and early SSI which, however, did not seem to impact survivals. Preoperative frailty was the predominant risk factor found in this series. Further studies are required to identify protective measures.

LEVEL OF EVIDENCE

III, case-control study.

Omentum support for cardiac regeneration in ischaemic cardiomyopathy models: a systematic scoping review

OBJECTIVES

Preclinical in vivo studies using omental tissue as a biomaterial for myocardial regeneration are promising and have not previously been collated. We aimed to evaluate the effects of the omentum as a support for bioengineered tissue therapy for cardiac regeneration in vivo. 

METHODS

A systematic scoping review was performed. Only English-language studies that used bioengineered cardio-regenerative tissue, omentum and ischaemic cardiomyopathy in vivo models were included.

RESULTS

We initially screened 1926 studies of which 17 were included in the final qualitative analysis. Among these, 11 were methodologically comparable and 6 were non-comparable. The use of the omentum improved the engraftment of bioengineered tissue by improving cell retention and reducing infarct size. Vascularization was also improved by the induction of angiogenesis in the transplanted tissue. Omentum-supported bioengineered grafts were associated with enhanced host reverse remodelling and improved haemodynamic measurements.

CONCLUSIONS

The omentum is a promising support for myocardial regenerative bioengineering in vivo. Future studies would benefit from more homogenous methodologies and reporting of outcomes to allow for direct comparison.

The Historical Role of the Plastic Surgeon in Spine Reconstruction

Wound complications occur in up to 19% of patients undergoing complex spine surgery. The role of the plastic surgeon in complex and redo spine surgery is important and evolving. Classically, plastic surgeons have been involved in the management of patients who develop wound complications following surgery. This involves reconstruction of posterior trunk defects with locoregional fasciocutaneous, muscle, and free tissue transfers. There has also been an increasing role for plastic surgeons to become involved in prophylactic closures of complex and/or redo spine surgeries for high-risk populations. Identification of patients with comorbidities and likelihood for multiple reoperations who are prophylactically treated with complex closure with or without local muscle flaps could significantly decrease the postoperative wound complications.

Locoregional Flap Closure for High-risk Multilevel Spine Surgery

Background:

Postoperative wound complications pose a challenge to patients undergoing complex spine surgery. Long-term sequelae can be devastating including decreased quality of life, meningitis, prolonged hospital stay, and need for reoperation. Among high-risk patients, postoperative wound complications have been shown to approach 40% in the literature. The aim of this study was to identify predictive factors for postoperative complications following soft-tissue reconstruction after high-risk spine surgery with the hypothesis that it would result in significantly fewer postoperative wound complications.

Methods:

A retrospective review of 67 consecutive spine operations at an academic, tertiary care center was performed, evaluating outcomes with a single plastic surgeon in conjunction with the spine surgery team. Data regarding patient demographics, perioperative risk variables, flap type, location of defect, and postoperative outcomes were obtained through retrospective chart review. Complications included soft-tissue complications and a number of reoperations. A bivariate analysis was used to identify predictors of postoperative complication. These data were compared to literature-reported averages.

Results:

A total of 67 consecutive spinal reconstructive operations were included with a mean follow-up of 11.8 months. Thirty-seven patients (55.2%) underwent immediate reconstruction at the time of the index operation, and 30 (44.8%) underwent delayed reconstruction for secondary wound healing problems following the index operation (in which plastic surgery was not involved). The majority of both immediate (95%, n = 35) and delayed (100%, n = 30) patients was defined as high risk based on literature standards. Patients in this series demonstrated a 7.5% complication rate, compared to 18.7% complication rate in the literature. We did not find a difference between major wound complications in the immediate (8.1%) or delayed (6.7%) reconstructive setting (P > 0.99). There were no specific variables identified that predicted postoperative complications.

Conclusion:

This study illustrates a postoperative complication rate of 7.5% among patients undergoing paraspinous or locoregional muscle flap closure by plastic surgery, which is significantly lower than that reported in contemporary literature for these high-risk patients.

Complex wound closure by plastic surgery following resection of spinal neoplasms minimizes postoperative wound complications in high-risk patients

OBJECTIVE

Wound breakdown and infection are common postoperative complications following resection of spinal neoplasms. Accordingly, it has become common practice at some centers for plastic surgeons to assist with closure of large posterior defects after spine tumor resection. In this study, the authors tested the hypothesis that plastic surgery closure of complex spinal defects improves wound outcomes following resection of spinal neoplastic disease.

METHODS

Electronic medical records of consecutive patients who underwent resection of a spinal neoplasm between June 2015 and January 2019 were retrospectively reviewed. Patients were separated into two subpopulations based on whether the surgical wound was closed by plastic surgery or neurosurgery. Patient demographics, preoperative risk factors, surgical details, and postoperative outcomes were collected in a central database and summarized using descriptive statistics. Outcomes of interest included rates of wound complication, reoperation, and mortality. Known preoperative risk factors for wound complication in spinal oncology were identified based on literature review and grouped categorically. The presence of each category of risk factors was then compared between groups. Univariate and multivariate linear regressions were applied to define associations between individual risk factors and wound complications.

RESULTS

One hundred six patients met inclusion criteria, including 60 wounds primarily closed by plastic surgery and 46 by neurosurgery. The plastic surgery population included more patients with systemic metastases (58% vs 37%, p = 0.029), prior radiation (53% vs 17%, p < 0.001), prior chemotherapy (37% vs 15%, p = 0.014), and sacral region tumors (25% vs 7%, p = 0.012), and more patients who underwent procedures requiring larger incisions (7.2 ± 3.6 vs 4.5 ± 2.6 levels, p < 0.001), prolonged operative time (413 ± 161 vs 301 ± 181 minutes, p = 0.001), and greater blood loss (906 ± 1106 vs 283 ± 373 ml, p < 0.001). The average number of risk factor categories present was significantly greater in the plastic surgery group (2.57 vs 1.74, p < 0.001). Despite the higher relative risk, the plastic surgery group did not experience a significantly higher rate of wound complication (28% vs 17%, p = 0.145), reoperation (17% vs 9%, p = 0.234), or all-cause mortality (30% vs 13%, p = 0.076). One patient died from wound-related complications in each group (p = 0.851). Regression analyses identified diabetes, multilevel instrumentation, and BMI as the factors associated with the greatest wound complications.

CONCLUSIONS

Involving plastic surgery in the closure of spinal wounds after resection of neoplasms may ameliorate expected increases in wound complications among higher-risk patients.

Omental flap for treatment of spondylodiscitis with lumbosacral dehiscence: A case report

We report a case of pedicled omental flap use together with osteosynthesis treatment of a chronic L4-L5 spondylodiscitis due to a large sacral eschar. The 43-years-old patient was paraplegic and had depleted regional flaps solutions due to multiple previous surgeries. The procedure was carried out in supine position then in prone position whereby the dissected flap was recovered through the spine. The surgery was performed by a multidisciplinary team. First, we used an anterior approach for spine osteosynthesis with a metal implant and flap harvest. Then, in a prone position, we completed the vertebral reconstruction by an L3 athrodesis to the pelvis. The flap was recovered through the spine defect, on the side of the implant. It was a right sided pedicled. Complete wound healing was 120 days. The omental flap proved to be a reliable solution in the absence of recipient vessels for free flap transfer and depleted regional flap solutions. It also spared the latissimus dorsi muscle required for a wheelchair user as in our case. The omental flap is still performed in spine surgery especially in oncologic context to prevent wound dehiscence and for spondylodiscitis coverage. The anterior approach allows for both spine osteosynthesis and flap dissection.

Immediate Reconstruction of Complex Spinal Wounds Is Associated with Increased Hardware Retention and Fewer Wound-related Complications: A Systematic Review and Meta-analysis

Supplemental Digital Content is available in the text.

Background:

Patients undergoing surgeries involving extensive posterior spine instrumentation and fusion often have multiple risk factors for wound healing complications. We performed a systematic review and meta-analysis of the available evidence on immediate (proactive/prophylactic) and delayed (reactive) spinal wound reconstruction. We hypothesized that immediate soft-tissue reconstruction of extensive spinal wounds would be associated with fewer postoperative surgicalsite complications than delayed reconstruction.

Methods:

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed database search was performed to identify English-language, human-subject literature published between 2003 and 2018. Data were summarized, and the pooled prevalence of various wound complications was calculated, weighted by study size, using the generic inverse variance method. A subgroup analysis of all studies with a comparison group (Oxford Centre for Evidence-based Medicine level 3 or better) was performed, and Forest plots were created.

Results:

The database search yielded 16 articles including 828 patients; 428 (51.7%) received an immediate spinal wound reconstruction and 400 (48.3%) had a delayed reconstruction. Spinal neoplasm was the most common index diagnosis. Paraspinous muscle flap reconstruction was performed in the majority of cases. Pooled analysis of all studies revealed immediate reconstruction to be associated with decreased rates of overall wound complications (28.5% versus 18.8%), hardware loss (10.7% versus 1.8%), and wound infections (10.7% versus 7.6%) compared with delayed reconstruction.

Conclusions:

Immediate soft-tissue reconstruction of high-risk spinal wounds is associated with fewer wound healing complications and increased hardware retention.

On-ward surgical management of wound dehiscence: report of a single neurosurgical center experience and comparison of safety and effectiveness with conventional treatment

The early identification and optimized treatment of wound dehiscence are a complex issue, with implications on the patient's clinical and psychological postoperative recovery and on healthcare system costs. The most widely accepted treatment is surgical debridement (also called "wash out"), performed in theater under general anesthesia (GA), followed by either wide-spectrum or targeted antibiotic therapy. Although usually effective, in some cases, such a strategy may be insufficient (generally ill, aged, or immunocompromised patients; poor tissue conditions). Moreover, open revision may still fail, requiring further surgery and, therefore, increasing patients' discomfort. Our objective was to compare the effectiveness, costs, and patients' satisfaction of conventional surgical revision with those of bedside wound dehiscence repair. In 8 years' time, we performed wound debridement in 130 patients. Two groups of patients were identified. Group A (66 subjects) underwent conventional revision under GA in theater; group B (64 cases) was treated under local anesthesia in a protected environment on the ward given their absolute refusal to receive further surgery under GA. Several variables-including length and costs of hospital stay, antibiotic treatment modalities, and success and resurgery rates-were compared. Permanent wound healing was observed within 2 weeks in 59 and 55 patients in groups A and B, respectively. Significantly reduced costs, shorter antibiotic courses, and similar success rates and satisfaction levels were observed in group B compared with group A. In our experience, the bedside treatment of wound dehiscence proved to be safe, effective, and well-tolerated.